Application for Homeowner Rehab Program

APPLICATION FOR HOMEOWNER REHAB PROGRAM

The information collected below will be used to determine whether you qualify for this program. It will not be disclosed without your consent except to your employer(s) for verification of income and employment information to financial institutions for verification of assets, and as required and permitted by law. You do not have to provide the information, but if you fail to do so, your application may be delayed or rejected.

1. Applicant’s Name / Social Security No. / Home Phone
( )
2. Present Street Address / City / State / Zip Code / No. of Years at
Present Address
3. Former Street Address (if at present address for less than 2 years) / City / State / Zip Code / No. of Years at
Former Address
4. Names of Other Persons in Household
5. Name and Address of Employer / Type of Business / Self Employed?
___ Yes ____ No
Business Phone Number
( ) / Position/Title / No. of Years on Job / Years in this line of work
6. Name and Address of Previous Employer (if employed at present position for less than 2 years / No. of Years with Previous Employer / Business Phone
( )
1. Co-Applicant’s Name / Social Security No. / Home Phone
( )
2. Present Street Address / City / State / Zip Code / No. of Years at
Present Address
3. Former Street Address (if at present address for less than 2 years) / City / State / Zip Code / No. of Years at
Former Address
4. Names of Other Persons in Household
5. Name and Address of Employer / Type of Business / Self Employed?
___ Yes ____ No
Business Phone Number
( ) / Position/Title / No. of Years on Job / Years in this line of work
6. Name and Address of Previous Employer (if employed at present position for less than 2 years / No. of Years with Previous Employer / Business Phone
( )

Rehab Form MFA_0.1Page 1 of 3

Rehab Application 03/05

APPLICATION

Page 2

ANNUAL INCOME

Source / Applicant / Co-Applicant / Other Household
Member 18
Years or Older / Total
Salary
Overtime Pay
Commissions
Fees
Tips
Bonuses
Interest and/or Dividends
Net Income from Business
Net Rental Income
Social Security, Pensions,
Retirement Funds etc.,
Received Periodically
Unemployment Benefits
Workers Compensation, etc.
Alimony, Child Support
Welfare Payments
Other:
TOTAL: ______

ASSETS

Assets / Cash
Value / Income
from
Assets / Name of Financial
Institution / Account Number
Checking Account / $ / $
$ / $
Savings / $ / $
$ / $
Credit Union / $ / $
$ / $
Mutual Funds / $ / $
Stocks/Bonds / $ / $
Other? / $ / $

APPLICATION

Page 3

HOUSEHOLD COMPOSITION

List the head of your household and all members who live in your home. Give the relationship of each family member to the head.

Member No. / Full Name / Relationship / Age / Social Security No.
Head of
Household
2
3
4
5
6
7
8
9
10

Does anyone live with you now who is not listed above?____ Yes____ No

Does anyone plan to live with you in the future

who is not listed above? ____ Yes____ No

Please explain if you answer “Yes” to either question above.

The information provided above is true and complete to the best of my/our knowledge and belief. I/we consent to the disclosure of income and financial information form my/our employer and financial references for purposes of income and asset verification related to my/our application for assistance.

ApplicantDate

Co-ApplicantDate

Rehab Form MFA_0.1Page 1 of 3

Rehab Application 03/05